Collaborative Practice Agreement for Nurse Practitioner Management of Patients in the Specialty of Pediatric Critical Care

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1 Collaborative Practice Agreement for Nurse Practitioner Management of Patients in the Specialty of Pediatric Critical Care Purpose Section I Introduction/Overview This document authorizes the nurse practitioner (NP) to perform medical acts in accordance with the Nursing Practice Act, , Texas Occupations Code and the Medical Practice Act, , Texas Occupations Code. This document delegates certain medical acts, as required by Texas law, and sets forth guidelines for collaboration between the delegating physician(s) and the nurse practitioner. This agreement is not intended to limit the health care services the nurse practitioner shall provide under his or her scope of practice, based on the advanced practice role and specialty authorized by the Texas Board of Nursing. These services include, but are not limited to, performing physical examinations and medical histories, ordering laboratory and radiologic exams, providing health promotion and safety instructions, management of acute episodic illness and chronic diseases, and referrals to other health care providers, as needed. Development, Revision, Review and Approval The protocols are developed collaboratively by the nurse practitioner and delegating physician. These protocols will be reviewed annually, dated, and signed by the above parties and any alternate physicians. The agreement and/or associated treatment guidelines will be revised more frequently as necessary. The Statement of Approval will be signed by all parties recognizing the collegial relationship between the parties and their intention to follow these protocols. Signature on the Statement of Approval implies approval of all the policies, protocols and procedures in this document. Nurse practitioners and physicians who join the staff after approval or renewal also review and sign the protocols. Education, Training, Certification, Licensure & Authorization to Practice The nurse practitioner must possess a valid, unencumbered license as a Registered Nurse from Texas or a compact party state. In addition, the NP must have documentation from the Texas Board of Nursing (BON) authorizing advanced nursing practice in a role and specialty appropriate to the patients for this site. If prescriptive authority is delegated, the NP must have a valid prescriptive authority number from the BON. If prescriptive authority for controlled substances is delegated, the NP must also have a Texas Department of Public Safety Controlled Substances Permit and a Drug Enforcement Agency (DEA) certificate. Copies of these records must be maintained in the NP s credentialing file. NPs shall provide the following information:

2 Current BLS & PALS provider certification as per Children's Medical Center of Dallas policy. Current Texas RN License with the BON (or a compact party state) Current/pending Texas NP recognition with the BON Current/pending prescription authorization number from the Texas BON Sanctions: The NP and physicians practicing under this protocol agree to notify one another of any sanctions imposed by any licensing board against the NP s or physician s license. Population and Setting The nurse practitioner will practice under these protocols in a facility based practice at: Facility 1: Children's Medical Center 1935 Medical District Drive Dallas, Texas Facility 2: Children s Medical Center Legacy 7601 Preston Road Plano, Texas Population includes those patients admitted to or consulted on by the Pediatric Critical Care service.

3 Section II Privileges & Scope of Practice Delegation of Medical Aspects of Care - Privileges 1. Core Privileges The scope of health care services provided by the NP may include, but are not limited to the following: Assessment and Diagnosis: a. Obtain a comprehensive developmental, health, and medical history. b. Perform physical examinations. c. Order and interpret tests, laboratory tests, and diagnostic procedures. d. Systematically compare and contrast clinical findings in formulating differential diagnosis. e. Assess and diagnosis illnesses, including chronic and acute/critical conditions. f. Consult with other health care providers as necessary. Interventions: a. Procedures and other methods of treatment that may be diagnostic and/or therapeutic may include but are not limited to: Oxygen and other medical gases Intravenous fluids and nutritional support Ordering the administration of pharmacologic interventions, which include all classes of dangerous drugs and Controlled Substances, Schedules II-V. b. Consult on patients in need of specific services. c. Provide appropriate follow-up care. d. Provide care that reflects evidence-based practice. e. Consult and collaborate with other health care providers as appropriate. f. Collaborate with the attending physician regarding communication of patient problems, status, and prognosis with the patient family members, referring physicians and other members of the health care team. g. Refer patients to appropriate health care providers for further medical management or consultation. Evaluation: a. Monitor and evaluate accuracy of diagnosis and effectiveness of prescribed treatment plans b. Monitor growth and development. c. Monitor child and family response to treatment. d. Modify interventions based on effectiveness, available evidence-based practice guidelines, and individual child and family needs and satisfaction. e. Participate in Quality Improvement processes to assure provision of quality health care. f. Synthesize and use the results of evaluation to make or recommend changes in practice including policy, procedure, or collaborative agreement.

4 Documentation a. Electronic medical record documentation or written documents may include: history and physical forms, daily progress notes, procedure notes, admission notes, consultation notes, telephone encounters, discharge notes, outpatient clinic encounter forms, and dictated letters/clinic summaries in the Medical Record. b. Computerized provider order entry in the electronic medical record or written orders on the Physicians Order Sheet, outpatient treatment orders, and prescriptions. Specialty Specific Privileges Prior to independently performing specialty procedures, competency will be determined by a documented skill check off. The skill check off will require that proficient performance of each skill be observed and documented by another NP, PICU fellow or attending physician with unrestricted practice privileges. Assurance of ongoing competency may be documented through annual chart audits, personal documentation by the NP as to the frequency of each skill preformed, or by annual Specialty Skills Training. The NP may perform the procedures listed in the form Delegated Specialty Specific Privileges (see Attachment). 2. Emergency Care In an emergency situation, the NP may provide care to stabilize a patient s condition and prevent deterioration that would otherwise be beyond the scope of this protocol. 3. Limited Scope of Practice All Nurse Practitioners will function within a scope of practice that is commensurate with his/her education and experience. Limited Scope of Practice will be applied until the Nurse Practitioner is fully credentialed to practice at Children's Medical Center and successfully completes a supervised orientation. Nurse Practitioners functioning under a Limited Scope of Practice require direct supervision (observation of activities and cosignature of progress notes/orders) by a preceptor that is a fully credentialed provider (MD or NP) at Children's Medical Center. Additionally, Primary Care Nurse Practitioners in the critical care settings must practice under complete supervision that includes co-signature of all notes, physical examinations, orders, and other medical record entries. The supervision must be by a credentialed acute care pediatric nurse practitioner, pediatric critical care nurse practitioner, or credentialed physician at Children's Medical Center Dallas. This limited scope of practice will continue until the nurse practitioner has received recognition from the Texas Board of Nursing as an Acute Care Pediatric Nurse Practitioner or Pediatric Critical Care Nurse Practitioner.

5 Section III Prescriptive Authority Carrying Out or Signing Prescriptions and Drug Orders The nurse practitioner may establish medical diagnoses for patients that are within the NPs scope of practice, and order or prescribe dangerous drugs and medical devices as authorized by the Texas Board of Nursing (BON) under Rules 221 and 222, and the Texas Medical Board (TMB) under Rules and The nurse practitioner may order or prescribe: 1. Dangerous drugs a. Any medication or device intrinsic to the medical practice of the supervising physician. b. Oxygen and other medical gases. c. All classes of dangerous drugs for inpatient or outpatient use at the licensed facility based practice. d. Investigational drugs as part of a research protocol. 2. The methods of ordering that the NP is authorized to use includes written or verbal orders on medical record order sheets and the method of prescribing includes written prescriptions. 3. Dangerous Drug Prescriptions: a. Write single signature prescriptions. b. The number of dosage units shall not exceed a ninety (90) day supply. c. The NP may authorize up to a 4-month supply of refills for acute conditions and up to a year supply of refills for chronic conditions. d. The NP shall provide appropriate instruction to the patient on use of any medications prescribed, including appropriate warnings and follow-up care. 4. The NP may authorize the dispensing of brand name medications as medically necessary. 5. Limitations on prescribing: a. The delegating physician must be the Medical Director of Specific Service or his/her designee. b. All ordering and prescribing must be for patients that are treated at the facility where the delegating physician is a credentialed provider. c. If practicing under the Limited Scope of Practice guidelines, the NP may not give verbal orders. 6. The physician designates any licensed vocational nurse or registered nurse working in this site as a person who may call a prescription into a pharmacy on behalf of the nurse practitioner.

6 7. The NP may direct the hospital pharmacy to dispense Controlled Substances, Schedule II for administration to in-patients or for patients requiring treatment in areas such as the emergency room or Critical Care Units (PICU, CVICU, Trauma/Neuro ICU) within the parameters specified below: The NP will discuss with the PICU attending physician initiation or changes in Schedule II medications in the development, implementation, and evaluation of a comprehensive plan of care. Schedule II drugs which the NP may select are: Drug Dose parameters Indication Morphine mg/kg IV Q 2 Pain Management hours or mg/kg/hr IV Continuous infusion and titrated to effect Hydromorphone mg/kg IV Q 1 hours Pain Management or mg/kg/hr IV Continuous infusion or mg/kg PO Q 4-6 hours and titrated to effect Fentanyl mcg/kg IV Q 1 hours Pain Management or mcg/kg/hr IV Continuous infusion and titrated to effect Methadone mg/kg IV Q 4 Pain Management and hours Withdrawal management mg/kg PO Q 4 hours and titrated to effect Codeine mg/kg PO Q 4 Pain Management hours Hydrocodone 0.2mg/kg PO Q3-4 hours Pain Management Meperidine mg/kg IV/PO Q2- Pain Management 4hours and titrated to effect Oxycodone mg/kg PO Q 3 Pain Management hours

7 Section IV Supervision & Evaluation Supervision & Documentation of Supervision The nurse practitioner is authorized to diagnose and prescribe under the collaborative agreement established in this document without the direct (on-site) supervision or approval of the supervising physicians. Consultation with the delegating physician, or designated alternate physicians, is available at all times on-site, by telephone, or by other electronic means of communication. Supervision shall be consistent with any requirement specified in TMB Rules, for the practice site identified in this agreement. Consultation The Nurse Practitioner is to immediately report any emergency situations after stabilizing the patient, and give a daily status report on any occurrences that fall outside the protocols. The NP will seek physician consultation when needed. Whenever a physician is consulted, a notation to that effect, including the physician's name should be recorded in the patient's medical record. Medical Records The nurse practitioner is responsible for the complete, legible documentation of all patient encounters that is consistent with state and federal laws. Evaluation of Clinical Care Evaluation of the nurse practitioner may be provided in the following ways: Presentation in daily rounds and ongoing discussion of patient management with the PICU attending physician NP Performance evaluation by the PICU attending physician at the end of his/her rotation Annual or, if necessary, more frequent evaluation of the NP by the delegating physician, department manager, and/or department director Periodic peer review Informal evaluation during consultations and case review

8 Section V Statement of Approval Collaborating Parties: Statement of Approval I affirm that I hold current licensure and approval (or provisional authorization) of the Texas Board of Nursing to practice as an advanced practice nurse in the State of Texas. I verify that I am competent to provide care to patients of the Pediatric Critical Care Service within my scope of practice as described in the attached protocols. I agree to review these protocols annually with the physicians listed below and have my practice monitored by the processes set out by Children s Quality Assurance/Improvement Plan. By my signature, I agree to be bound by the Constitution, Rules and Regulations, and Policies and Procedures of the Medical/Dental Staff pertaining to clinical privileges and understand that non-compliance with either one may constitute grounds for withdrawal or restriction of privileges. Nurse Practitioner [insert name] I agree that insert name is competent to provide care to patients of the Pediatric Critical Care Service as described in the attached protocols and scope of practice. These protocols have been developed and reviewed in accordance with the policies of Children s Medical Center. The care rendered by insert name will be monitored in accordance with the Quality Assurance/Improvement Plan of Children s. Variance from the established quality indicators or standards of care set by the Pediatric Critical Care Service will be reviewed by the appropriate Peer Review Committee. I hereby verify that I will provide oversight of the above listed Advanced Practice Nurse who will function within the guidelines of the privileges, protocols or scope of practice under my direction. I also agree to notify the Medical Staff Services Office of any changes in this arrangement. Medical Director/Medical Director Designee [insert name]

9 Authorization to Function in Advanced Clinical Role By my signature, I request to function in an advanced clinical role. I affirm that I have the required education, training and experience to function in this capacity. I agree to be bound by all Policies and Procedures of Children s Medical Center and to abide by the pertinent sections of the Medical/Dental Staff Constitution, Rules, Regulations and/or Policies. I understand that non-compliance may constitute grounds for limitation of my scope of practice or dismissal from Children s Medical Center. APPLICANT: insert name SIGNATURE: APPROVED APPROVED BY: BY: Director of Advanced Practice Services Division Director Chief Nursing Officer MEC Approval (see minutes): BOD Approval (see minutes):

10 Delegated Specialty Specific Procedures NAME: insert name DEPARTMENT/SERVICE AREA: Pediatric Critical Care Delegated specialty specific procedures are based on the individual s competency and experience. Level of supervision will be verified by the department s physician director or designee at time of initial credentialing and with each re-credentialing cycle unless substantive changes occur. Instructions: Proficiency must be initially verified for all procedures, diagnostic studies and special medications listed below to be performed/prescribed by the NP. Documentation of proficiency must be kept with the date and initials/signature of the credentialed provider performing the verification. The level of supervision needed by the NP will be documented below: Procedure, Diagnostic Studies, Special Medications Direct Supervision Indirect Supervision Available Arterial Line Placement Granted Granted Granted Central Venous Line Placement Granted Granted Granted Chest Tube Placement Granted Granted Granted Endotracheal Intubation Granted Granted Granted Lumbar Puncture Granted Granted Granted Needle Thoracentesis Granted Granted Granted PICC line placement Granted Granted Granted Pulmonary Artery Catheter Placement Granted NA NA Medical Director/Medical Director Designee Insert name

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